Why the GOP health care plans are so bad

It’s easy to find mainstream people who hate the latest Republican effort to kill the Affordable Care Act. Because that’s almost everybody.

Doctors, represented by the American Medical Association, are against the Cassidy-Graham bill, which is the third and probably final effort to kill Obamacare this year. The American Cancer Society and just about all other patient advocacy groups are against it. So are insurers, drugmakers and hospitals. The AARP, the influential lobbying group for seniors, strongly opposes it. So do all Democrats everywhere, at least four Republican governors and some other conservatives.

Public approval of the Republican effort to kill Obamacare rests well below 20%, while approval of Obamacare itself has crested 50%. By some measures, the law Republicans want to kill is three times as popular as the law they want to replace it with. Public approval could go even lower as talk-show host Jimmy Kimmel continues his crusade against the Cassidy-Graham approach and other entertainers pile on.

Yet Majority Leader Mitch McConnell and his lieutenants are determined to try for a third time to kill Obamacare — and they might succeed. There will be just one public hearing on Cassidy-Graham before the Senate votes, and the Congressional Budget Office won’t even have time to analyze the bill’s likely effect on the federal budget and the number of Americans with insurance by then. If there were ever a ramrod piece of legislation that you’d think wouldn’t have a prayer, this is it.

Yet, there is a realistic chance the Senate will pass Cassidy-Graham in the coming days. If it does, the House will probably pass it as well, and President Donald Trump has said he’ll sign it. So how have we come to a point where Washington might enact legislation the majority of voters say they don’t want?

How could such hated legislation pass

Part of the answer may involve campaign money. The conservative Koch Brothers network has promised to donate up to $400 million to favored candidates in 2018, and two of their top agenda items are repealing Obamacare and cutting taxes. Koch-backed groups such as Americans for Prosperity, a super PAC, aren’t thrilled with the Cassidy-Graham bill, because they feel it doesn’t go far enough. The bill would end most of the ACA’s major provisions, and spend billions less on health care overall, probably leading to a big drop in the number of people covered by Medicaid. Many conservatives applaud cutbacks in this sprawling program that mostly benefits the poor.

Charles Koch (L) and David Koch are pictured in this combination photo. REUTERS/Freedom Partners Chamber of Commerce/Handout/Carlo Allegri

Some conservatives feel the Cassidy-Graham bill still includes too much taxpayer funding for health care, which is why they’re lukewarm on the bill. But it’s probably the last chance to repeal Obamacare for the foreseeable future, because Senate rules change after Sept. 30, requiring 60 votes rather than 51 to pass most legislation. Killing Obamacare has a link to tax cuts, because it would free up some government revenue that could be used to lower tax rates. So for any Republican legislator hoping to fulfill the Koch agenda — and claim a share of the network’s campaign money — it all begins with killing Obamacare, no matter what the public thinks.

Republicans are also stuck with a foolish promise they made over and over for the past seven years — to repeal and replace Obamacare, even though there was no plan to replace it with. “They’re prisoners of their own promise,” says Jim Kessler, senior vice president at the centrist think tank Third Way. “If you’re a Republican, it’s better to keep the bad promise you made than reject what everyone knows is wrong.” Kessler, like others, says Republican legislators privately complain about being stuck in such an unpopular position. But the expedient thing to do is fulfill the promise first, then worry about the ramifications later.

The consequences

And the ramifications could be severe if Republicans finally get their way and roll back Obamacare. The Cassidy-Graham plan is complex, and organizations such as Health Affairs and Kaiser Health News have outlined the details for those who want the nitty-gritty. In general, it would shift spending away from the 14 states that expanded Medicaid under the ACA (which are mostly blue states controlled by Democrats), and move it toward Republican-controlled red states that didn’t expand Medicaid. And the money would go to states as block grants they can spend as they wish, instead of the spending being controlled by Washington.

Overall, the federal government would spend billions less on health care under the bill. Supporters say that’s okay, because states would spend the money more efficiently than Washington, and therefore be able to cover the same number of people as Obamacare. But there’s no evidence states get more bang for the buck out of taxpayer money, and they might even be more inefficient, since administration of certain functions would devolve from one centralized operation in Washington to more than 50, including U.S. territories. So it’s very likely Cassidy-Graham would lead to a big cutback in the number of people with insurance, as other GOP health plans would have. We’ll have a better idea in October, when the CBO weighs in, but that will be after the Senate votes.

Trump and other supporters claim the latest GOP bill will retain protections for people with pre-existing conditions, one of the most popular provisions of Obamacare. Yet the bill says explicitly that states can “waive” such rules, and it would also allow insurers to charge people more based on their health.

What Cassidy Graham means for the upcoming election

Meanwhile, the bill does nothing to address the many factors that push health care costs higher and higher, even for people completely unaffected by Obamacare. So on net, Cassidy-Graham would leave more people uninsured, restore disparities that make care considerably more expensive for the sick, and scale back a program that’s the last source of health care for many low-income Americans.

Couldn’t this cause problems for Republicans come election time? Yes! But the party dominated by Trump either thinks it’s invincible, or has simply lost track of what voters really want. “Republicans are just trying to make it over the next hill, get through the next procedural vote,” says Kessler. “The next election seems light years away.”

But 2018 will arrive quickly, bringing the risk that Republicans could lose control of one or both houses of Congress. If the Cassidy-Graham bill passes, millions of Americans will be preparing for the consequences by election time, but the bill wouldn’t go into effect until 2019. That, however, would make the GOP health care plan a top issue in the 2020 presidential election. Given that the Republicans barely have a plan, they’d probably prefer that didn’t happen.